Need help with Nursing Diagnosis (cervical Spondylosis)

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Hello. I need help with this neuro care-plan. I have diagnosis of Cervical Spondylosis and other condition is CHF, DM and varicose vein.

I tried to send my 1st draft to the teacher..and she killed me with some comments.

My first acute problem is pain..

so my nursing diagnosis is pain r/t degenerative joint disease AEB pt stated, "pain on my right shoulder," pain level 6/10, right hand weakness (fifth finger), Bp 171/92

Second

Fearlessness over loss of body function AEB: patient shedding tears, patient asked, "will I be okay?

Third: anxiety r/t upcoming surgery AEB: pt asking questions about surgery and pt stated, "i'm scared."

what is wrong here? Can someone help me with this? I'm in cardiac subject, but my clinical subject is neuro based and i haven't got to that subject in lecture.

can anyone come up with the nursing diagnosis?

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Specializes in OR, Nursing Professional Development.

Firstly, nursing diagnoses do not depend on the medical diagnoses. They depend on your patient's assessment. If you do not already have one, I suggest getting the NANDA book, not just the one recommended by your school. I'm not sure your second diagnosis is even approved by NANDA. I know things have changed since I last did them, but that one seems a bit of a stretch to me.

Secondly, utilize the search bar in the upper right part of the website to search for Esme, GrnTea, and nursing diagnosis. Esme and GrnTea are two of our experienced posters who have posted a lot of helpful posts about nursing diagnosis.

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Rose_Queen said:
Firstly, nursing diagnoses do not depend on the medical diagnoses. They depend on your patient's assessment. If you do not already have one, I suggest getting the NANDA book, not just the one recommended by your school. I'm not sure your second diagnosis is even approved by NANDA. I know things have changed since I last did them, but that one seems a bit of a stretch to me.

Secondly, utilize the search bar in the upper right part of the website to search for Esme, GrnTea, and nursing diagnosis. Esme and GrnTea are two of our experienced posters who have posted a lot of helpful posts about nursing diagnosis.

Ah okay..I'm new here..so I didn't know who to ask...and I'll ask them. thx.

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Specializes in L&D.

"Activity intolerance RT pain secondary to degenerative bone disease?"

And your second one is good, but I would re-word it to something along the lines of "fear of loss of control RT blah blah"

Good luck!

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2k15NurseExtern4u said:
"Activity intolerance RT pain secondary to degenerative bone disease?"

And your second one is good, but I would re-word it to something along the lines of "fear of loss of control RT blah blah"

Good luck!

much love! thanks!

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Specializes in Pain, critical care, administration, med.

Did you consider her other diagnoses? If the patient is having surgery that will be important. It always isn't the most obvious. Have to look at the whole patient. As your gain more experience you will develop it. Just think about what are the most important things I need to consider.

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Specializes in 15 years in ICU, 22 years in PACU.

When we're making a Nursing Diagnosis the Medical Diagnosis really doesn't matter.

A Nursing Diagnosis is based on our nursing assessment. So I could go into a patient's room and collect my own data (interview, observe, take vital signs etc.) and make some of the most meaningful (important to the patient) Nursing Diagnoses before I even know what the admitting Medical Diagnosis is.

I think that's where nursing students get off track. They're given a Medical Diagnosis to work up and create a care plan without having their own nursing assessment to work from.

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Specializes in Pain, critical care, administration, med.

You need to consider the medical, social, etc, diagnoses/problems to develop the nursing diagnoses. Students yes are learning so for them to be so fancy with their "own/diagnosis Its not that cut and dry.

Preoperative spinal patient with major comorbidities. Lots of nursing diagnoses from just that information alone. Make it simple!

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Thanks everyone. This helps me a lot.

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